Dr. Vanni is a graduate of Princeton University and earned his medical degree from the University of Colorado. He completed a 6 year urology residency at the Lahey Clinic, followed by a fellowship in Trauma and Reconstructive Urology from the University of Washington. He has published numerous manuscripts and book chapters, and is active in developing cutting edge reconstructive techniques.

Dr. Vanni is a member of the Trauma and Urologic Research Network of Surgeons (TURNS-http://turnsresearch.org). Lahey Hospital and Medical Center is one of 12 centers that collaborate in the study of patients treated for a variety of conditions in trauma and reconstructive urology, including urethral stricture surgery, male incontinence, and a variety of other conditions.

Introduction

A concealed or “buried” penis is a penile shaft below the surface of the prepubic skin. This can result in either a partially or completely concealed penis. There are multiple etiologies of the adult “buried” penis including obesity, aging, overly aggressive circumcision, large weight loss, Lichen Sclerosis, and previous penile surgery (i.e. previous Y-V advancement flap or partial penectomy). The resulting pathology of a “buried” penis can result in a significantly diminished quality of life with extreme difficulty voiding, skin breakdown, and sexual dysfunction. The surgical correction of a concealed penis is a complex reconstructive endeavor, that when properly performed, has excellent aesthetic and functional results.

Surgical Technique

1. Determination of the etiology of the concealed penis and adequacy of penile shaft skin. Multiple factors are often at play and this judgment is critical in determining the correct reconstructive procedure. Whether the suprapubic fat pad contributes to the buried penis is important and should be marked with the patient in the standing position preoperatively. The penile skin is best appreciated under anesthesia when the local tissues can be retracted and any constrictive scars or adhesions released.

2. Modified panniculectomy: An elliptical incision is made on the pre-marked escutcheon. The upper limit of the resection is usually the upper line created by the panniculus or just below this line. Care must be taken not to remove too much skin. The resection is taken just anterior to the anterior rectus fascia, leaving some lymphatic drainage in place.

3. Penopubic fixation: Several rows of tacking sutures (0-polyester) are placed from the lower edge of the flap and secured to either the periosteum of the symphysis or the anterior rectus fascia.

4. Two closed suction drains are placed in the subcutaneous tissue, which remain in place until minimal output.

5. The wound is closed in multiple layers with absorbable sutures and nylon skin closure.

6. Penile reconstruction: The type of reconstruction will depend on the adequacy of penile skin. An assessment is made to determine if the penile skin can be managed with primary release of adhesions with closure, or Z-plasty reconstruction. In cases of unsalvageable skin, the diseased tissue is resected from the coronal sulcus to the penile base, leaving dartos in place. With the penis on maximal stretch (or artificial erection), the dimensions are measured for skin graft placement.

7. Split thickness skin graft: The dimensions of the graft are marked on the anterior/lateral thigh. The thigh is prepared with mineral oil, and a dermatome used to harvest a split thickness skin graft (0.0012-0.0018 in). The graft is anchored to the penopubic junction and coronal sulcus with 4-0 chromic sutures. Fibrin glue is sometimes used to secure the graft in place. A modified Z-plasty is performed ventrally to minimize graft contracture.

8. Scrotoplasty: The type of scrotal reconstruction necessary depends in part on the type of penile reconstruction that is performed. In cases of skin grafting the scrotum and proximal skin graft are tacked to the underlying darts or tunica albuginea. If skin grafting is unnecessary, scrotal reconstruction with a Z-plasty at the penoscrotal junction is performed. This should be anchored to the underlying tunica albuginea to prevent the penis from retracting into the scrotal tissue.

Postoperative Care

1. Closed suction drains are left in place until minimal output.

2. If skin grafting is performed, the patient is on bed rest for 5 days, which subcutaneous heparin.

3. Panniculectomy sutures are removed at 2 weeks.

References

1. Alter GJ and Ehrlich RM. A new technique for correction of the hidden penis in children and adults. J Urol. 161:455-459, 1999.